Modern footwear inflicts a heavy toll on people's feet, especially the
toes. Adverse genetic or hereditary factors acting on the big toe (hallux) provide an additional recipe for deformity, which may deteriorate throughout life (hallux valgus).

When the big toe swings laterally, it either pushes the small toes ahead of it, or the second and sometimes third toes lift upwards, producing secondary deformities.

Sub-specialism within orthopaedics has meant that painful foot and ankle problems can be dealt with by experts who essentially only operate on that part of the human body. Simply visiting an orthopaedic surgeon for a foot or ankle opinion does not necessarily mean that the surgeon will operate, since there is a whole range of conservative treatments available. However, if symptoms are severe, progressive and unremitting, and especially if interfering with lifestyle, sports or work, surgery may be considered.

The following short-list of topics includes most common
forefoot problems encountered in clinical practice.

Bunions (Hallux Valgus)

Women are the main sufferers. It can even begin as early as adolescence, but most
patients are in early adult life when the first signs appear and it may or may not progress in severity with advancing age.

Fig 1. Typical Bunions

There is deformity of the big toes (Hallux Valgus). Pain occurs over the medial prominences of the first metatarsal heads due to shoe-rubbing.
Symptoms are very variable ranging from very mild pain only, which does not require surgery, through to severe pain due to shoe-rubbing on the inside of the first metatarsal head. A red inflamed bursa develops. There is little in the way of conservative treatment apart from paying special attention to extra wide footwear and making sure the shoe fits properly around the heel so that the foot is not pistoning up and down inside the shoe causing shear forces.

Surgical treatment usually involves sawing through the metatarsal bone or proximal phalanx, or both, and straightening the toe to correct the deformity, usually obtaining
fixation of the bones by screws or staples. The success rate is nine out of ten, with a small percentage of patients developing complications including stiffness and recurrent deformity.

Osteoarthritis of the first metatarsophalangeal joint (Hallux Rigidus)

Although this occasionally starts during early adult life, the most common sufferers are the middle aged and elderly. The condition again presents with pain in and around the first metatarsophalangeal joint, and in advanced cases, a large dorsal osteophyte (bone spur) builds up to cause additional pain due to pressure from the upper of the shoe. It is easily
diagnosed on an X-ray.

Fig 4. Main picture large dorsal swelling in a patient with hallux rigidus.
Inset: x-ray showing loss of joint space.

There are a variety of treatments depending upon the severity of the symptoms and the degree of advancement of the condition radiologically. NSAIDs and shoe modifications with stiffening of the sole and/or rocker bar may help some patients in the early stages.
As the condition progresses, temporary benefit may result from manipulation under anaesthesia with cortisone injection into the joint. If the condition is bad enough for surgery, then a cheilectomy procedure (removal of debris and bone spurs) provides good and usually lasting pain relief. In advanced cases, surgery in the form of joint replacement (arthroplasty) or fusion (arthrodesis) are the two main options.

Joint replacement is generally to be preferred as it allows some residual movement in the joint, although one drawback is implant failure due to infection or wearing-out.

Fig 5. Total Joint Replacement made from metal and ceramic used to treat Hallux Rigidus

The second and sometimes third toes are often secondarily involved when
there is Hallux Valgus.

They are described as claw toes, hammertoes or mallet toes, depending on which joints are deformed, but patients will get pain due to rubbing of the toe on the toe box of the shoe, producing a tender callosity or corn over the prominent part.

This can be treated by close attention to footwear or simple padding and/or chiropody, or can be corrected by a variety of surgical techniques, which may involve fusion of one or more joints in the toe, sometimes using temporary K wires.

This simply means "pain under the metatarsal heads". It has a variety of causes, the commonest being a fibrous swelling on an interdigital nerve (Morton's neuroma), or increased pressure under individual metatarsal heads. If the diagnosis is not clear, patients may need investigations which could include plain X-rays, ultrasound scan, MRI scan, CT scan, nerve
conduction tests, and pedobarography (force plate analysis).

If the condition proves to be one of pressure metatarsalgia, the safest initial treatment is to provide the patient with anterior metatarsal pads, either from a chiropodist, podiatrist, or a surgical appliance department. This off-loads the painful areas providing symptomatic relief.

In Morton's neuroma, most sufferers are middle aged females. They occur either in the 2/3 or the 3/4 intermetatarsal spaces. Characteristically, the patient complains of severe metatarsal pain radiating into the affected toes on walking, often worse in a tight or fashionable shoe, and eased by wearing wide shoes or walking barefoot. There may be numbness in the toes. If this condition is diagnosed, the best treatment is surgical removal of the neuroma, usually performed through an incision on the sole of the foot, with a nine out of ten chance of success.

Fig 6. Operative excision of a Morton's neuroma through a plantar incision on the sole of the foot.

In summary, the decision to operate or not in any individual patient depends on a number of factors including the duration of symptoms, their severity, the effect they have on the patient's life, and the rate of deterioration. Patients require adequate informed pre-operative consent to enable them to understand the risks associated with surgery, and also to appreciate its limitations. They need to be warned that recovery is often prolonged, especially if there are any setbacks such as prolonged swelling or wound infection. On the whole, whilst bunion surgery is reasonably rewarding, it does not yet have the reputation for "outstanding success" which usually follows total hip or knee arthroplasty. Bunion surgery usually results in a degree of improvement of symptoms, but there is often a mild continuing source of irritation such as stiffness, scar problems or mild imperfection in the position of the toe, which may need to be accepted.

The best results inevitably follow carefully planned surgery, performed for the appropriate, well-informed patient by a skilled, experienced foot and ankle surgeon. In some patients, permanent improvement may follow selective lesser metatarsal surgery to elevate individual metatarsal heads in order to relieve them of excessive load-bearing, but the results of this type of surgery are a little unpredictable.